Transcript Medical Ethics Board Review

Medical Ethics
Medical Ethics
[vs. Professional ethics]
 Ethical dilemma is a predicament in which
there is no clear course to resolve the
problem of conflicting moral principles
Principles
 Autonomy
 Beneficience
 Nonmaleficence
 Justice
Autonomy
 Freedom to influence course of
life/treatment
– Requires the person to be competent in
decision making capacity
Preservation of Autonomy
 Living Will
• Takes effect when terminally ill and lacking
decision making capacity
 Surrogate Decision Makers
– Represents patients interest
Preservation of Autonomy
 The primary responsibility of the physician
is to serve the patients interest
The patient self determination
act of 1990
 At the time of admission information re:
the patients’ right to refuse care or create
an advance directive must be dispensed
Informed Consent
 Patient is presented all alternatives so they can
make a decision. Must be competent
 Requirements
– Decision making capacity
– Volutariness
– Reasonable person standard
 Present all alternatives f/b recommendation
 Respect refusal
 All surgical and experimental procedures
Implied Consent
 Invoked when in emergency situations
when harm would result without urgently
needed intervention
Disclosure
 Truth telling on part of physician is an
integral part of patient autonomy
Paternalism
 Justifiable if patient at risk of significant
preventable harm, paternalistic action will
prevent harm, benefits outweigh risks and
the least autonomy-restrictive course of
action is used
Confidentiality
 Obligation of physician to maintain information
in strict confidence
 Breaching patient confidentiality may be merited
only:
– When ordered by court of law – a court case
– Where statutory requirement – public health laws
– Where required in health professional’s defense –
malpractice suit
– Where necessary for appropriate patient carespeaking to another provider in the medical care
system
 The percentage of patients who would like to be
told their diagnosis if it is a:
Metastatic cancer
Prognosis
European Americans
87%
African Americans
88%
Mexican Americans
65%
Korean Americans
47%
Ethiopians (can you guess?)??%
Terminal
69%
63%
48%
35%
??%
Source: Blackhall LJ, et al. (1995) JAMA 274: 820-5.
 The more traditional the culture … the less truth
telling regarding patient condition
Beneficience
 Obligation to preserve life, restore health,
relieve suffering and maintain function
 To do “good”
 Nonabandonment – obligation to provide
ongoing care
 Conflict of interest – must not engage in
activities that are not in patients best
interest
Nonmaleficence
 “Do no harm”
Justice
 Allocation of medical resources must be
fair and according to need
 Physicians should not make decisions
regarding individuals based upon societal
needs
DNR
 DNR orders affect CPR only
 Other therapies should not be influenced
by DNR order
 Should be reviewed frequently
 Rationale should be in medical record
Persistent Vegetative State
 Uncnsciousness/ loss of self awareness
lasting more than weeks
 Supreme court draws no distinction
between artificial feeding, hydration vs.
mechanical ventilation
Death
 Irreversible cessation of circulatory and
respiratory function
 Irreversible cessation of all brain function
(including brainstem)
Ethical Dilemas
 Euthanasia
– Legally prohibited in the US except in Oregon
which permits MD assisted suicide
 Destroying Frozen Embryos
Case Studies
 Lake, your 36-year-old patient, has just
tested positive for HIV. He asks that you
not inform his wife of the results and
claims he is not ready to tell her yet.
Case Studies
 22 year-old woman, is admitted to the
hospital with a headache, stiff neck and
photophobia but an intact mental status.
Lab tests reveal contagious meningitis. She
refuses treatment for it.
 A 25 year old woman victim of a single car
MVA enters a persistent vegetative state.
After four years, her parents petition to
have her feeding tube removed. The
hospital insists on a court order, and the
victim’s closest friend and parents testify
that she would not have wanted to have a
feeding tube.